Describe the pathophysiology of local and systemic responses to burn injury.

1.Local response: Burn injury immediately destroys cells or so fully disrupts their metabolic functions that cellular death ensues.
2.Systemic response: Other organ systems become involved in a general response to the stress caused by the burn.

Classify burn injury according to depth, extent, and severity based on established standards.

1.Depth:
1.Superficial burns: A burn injury in which only a superficial layer of epidermal cells is destroyed; also known as first-degree burn.
2.Partial-thickness burns: A burn injury that extends through the epidermis to the dermis; considered a deep partial-thickness injury if it extends to the basal layers of the skin; also known as a second-degree burn.
3.Full-thickness burns: A burn injury in which the entire thickness of the epidermis and dermis is destroyed; also known as a third-degree burn.
2.Extent and severity:
1.Rule of nines: A method to estimate burn injury that divides the total body surface area into segments that are multiples of 9%.
2.Lund and Browder chart: A method to estimate burn injury that assigns specific numbers to each body part and that accounts for developmental changes in percentages of body surface area.
3.American Burn Association categorization: This method is based on extent, depth, and location of burn injury; age of the patient; etiological agents involved; presence of inhalation injury; and coexisting injuries or preexisting illness.

Discuss the pathophysiology of burn shock as a basis for key signs and symptoms.

1.The pathophysiology of burn shock includes local and systemic responses to thermal trauma which are the basis for edema and accumulation of vascular fluid in the tissues in the area of injury.

Outline the physical examination of the burned patient.

1.Physical examination of the burned patient:
1.At the start of the physical examination, the paramedic should obtain a full set of vitals
1.The paramedic should obtain blood pressure in an unburned extremity, if available.
2.If all extremities are burned, the paramedic may place sterile gauze under the blood pressure cuff and attempt to auscultate blood pressure.
2.Patients with severe burns or preexisting cardiac or medical illness should be monitored by electrocardiogram.
3.Field care and hospital destination are determined by the depth, size, location, and extent of burned tissue and the presence of associated illness or injury.

Describe the prehospital management of the patient who has sustained a burn injury.

1.Prehospital management for the patient who has sustained a burn injury should include preventing further tissue injury, maintaining th airway, administering oxygen and ventilatory support, providing fluid resuscitation (per protocol), providing rapid transport to an appropriate medical facility, using clean technique to minimize the patient's exposure to infectious agents, and providing psychological and emotional support.

Describe pathophysiology as a basis for key signs, symptoms, and management of the patient with an inhalation injury.

1.Specific chemical injuries:
1.Petroleum:
1.Complications: Systemic effects such as central nervous system depression, organ failure, and death.
2.Management: Copious irrigation with water.
2.Hydrofluoric acid:
1.Complications: Has the potential to produce deep, painful, and severe injuries.
2.Management: Irrigation of the exposed area with large amounts of water should be started immediately.
3.Phenol:
1.Complications: Central nervous system depression, dysrhythmias, respiratory failure.
2.Management: Wounds should be irrigated with large volumes of water.
4.Ammonia:
1.Complications: Hazardous if introduced into the eye and may result in tissue necrosis and blindness.
2.Management: Irrigate with water or a balanced salt solution for up to 24 hours.
5.Alkali metals:
1.Complications: React with water and produce large amounts of heat.
2.Management: Physically removing the metal or covering it with oil minimizes the thermal injury.

Describe the physiological effects of electrical injuries as they relate to each body system based on an understanding of key principles of electricity.

1.Physiological effects of electrical injuries:
1.Integumentary system: Direct contact and passage of the current through tissue may cause wide areas of coagulation necrosis.
2.Circulatory system:
1.Hypertension and tachycardia associated with a large release of catecholamines.
2.Extensive necrosis of blood vessels.
3.Nervous system: Central nervous system damage may result in seizures or coma with or without focal neurological findings.
4.Musculoskeletal system: Damage within the extremities is similar to crush injury.
5.Renal system: Acute renal failure may result from a combination of myoglobin or hemoglobin precipitationg out of solution in the renal tubules, disseminated intravascular coagulation caused by tissue damage, hypovolemic shock, and direct current damage.
6.Respiratory system: Ventilation may be impaired due to central nervous system injury or chest wall dysfunction.
7.Sensory system: Conjunctival and corneal burns and ruptured tympanic membranes are common.

Outline assessment and management of the patient with electrical injury.

1.Assessment and management of the patient with electrical injury:
1.Initial assessment:
1.Patient's chief complaint.
2.Source, voltage, and amperage of the electrical injury.
3.Duration of contact.
4.Level of consciousness before and after the injury.
5.Significant medical history.
2.Physical examination:
1.Should be thorough.
2.Internal damage from electrical current may be much more significant than external wounds.
3.Management:
1.Early administration of fluids is critical.
2.In the emergency department or during interhispital transfer, the patient's intravenous fluid rates will be regulated to maintain a urine output of 75 to 100 mL/hr.

Describe the distinguishing features of radiation injury and considerations in the prehospital management of these patients.

1.Radiation injury:
1.Distinguishing features of radiation injury include nausea, vomiting, and diarrhea that begin within 2 to 4 hours.
2.Considerations in the prehospital management of these patients include dealing with contaminants and containing their spread.

Describe the incidence, morbidity, and mortality related to spinal injury.

1.Spinal injury:
1.Incidence: Highest in men between between ages 16 and 30 years.
2.Morbidity and mortality: Forty percent of trauma patients with neurological deficit will have a temporary or permanent SCI.

1.Spinal anatomy and physiology:
1.The spinal column is composed of 33 bones (vertebrae).
2.Each vertebra consists of a solid body (bearing most of the weight of the vertebral column), a posterior and anterior arch, a posterior spinous process, and in some vertebrae, a transverse process.

Outline the general assessment of a patient with suspected spinal injury.

1.General assessment of a patient with suspected spinal injury:
1.Axial loading: Vertical compression of the spine that results when direct forces are transmitted along the length of the spinal column.
2.Flexion, hyperextension, and hyperrotation: May result in fracture, ligament injury, or muscle injury.
3.Lateral bending: May result in dislocations and bony fractures to the cervical and thoracic spine.
4.Distraction: May occur if the cervical spine is stopped suddenly while the weight and momentum of the body pull away from it.
5.Other mechanisms: Blunt and penetrating trauma and electrical injury.

Distinguish between types of spinal injury.

1.Types of spinal injury:
1.Sprains and strains: Usually result from hyperflexion and hyperextension forces.
2.Fractures and dislocations: The most frequently injured spinal regions in descending order are C5 to C7, C1 to C2, and T12 to L2.
3.Sacral and coccygeal fractures: May result in loss of perianal sensorimotor function.
4.Cord injuries:
1.Cord lesions:
1.Central cord syndrome:
1.Paralysis of the arms.
2.Sacral sparing.
2.Anterior cord syndrome:
1.Decreased sensation of pain and temperature below the level of the lesion.
2.Intact light touch and position sensation.
3.Paralysis.
3.Brown-Sequard Syndrome: hemitransection of the spinal cord.

Describe prehospital evaluation and assessment of spinal cord injury.

1.Motor findings:
1.Upper extremity neurological function assessment: To test intraosseous muscle function (controlled by T1 nerve roots), the paramedic should instruct the patient to spread the fingers of both hands.
2.Lower extremity neurological function assessment: To test plantar flexors of the foot (controlled by S1 and S2 nerve roots), the paramedic should place his or her hands at the sole of each foot and instruct the patient to push against the hands.
2.Sensory findings:
1.C2 to C4 dermatomes provide a collar of sensation around the neck and over the anterior chest to below the clavicles.
2.T4 dermatome provides sensation to the nipple line.
3.T10 dermatome provides sensation to the umbilicus.
4.S1 dermatome provides sensation to the soles of the feet.
3.Reflex reponses: Seldom are evaluated in the prehospital setting.
4.Other methods of evaluation: A visual inspection of the spine may reveal the presence of injury and its level.

Discuss the factor and mechanism of injury associated with thoracic trauma.

1.Thoracic trauma is often the result of motor vehicle crashes, falls from heights, blast injuries, blows to the chest, chest compression, gunshot wounds, and stab wounds.

Describe the mechanism of injury, signs and symptoms, and management of skeletal injuries to the chest.

1.Mechanism of injury: May be caused by blunt or penetrating trauma.
2.Signs and symptoms:
1.Clavicular fractures: Pain, point tenderness, and evident deformity.
2.Rib fractures: Usually are very painful.
3.Flail chest: Injured segment of the chest may begin to move in a paradoxical (contrary) fashion with inspiration and expiration.
4.Sternal fractures: history of significant anterior chest trauma, tenderness, and abnormal motion or crepitation over the sternum.
3.Management:
1.Clavicular fractures: Usually involves applying a clavicle strap or a sling and swathe that immobilizes the affected shoulder and arm.
2.Rib fractures: Relieve pain.
3.Flail chest: Includes assissting ventilation with positive pressure by means of a bag-mask device, use of high-concentration oxygen, and fluid replacement as needed.
4.Sternal fractures: Includes maintaining a high degree of suspicion for associated injuries, airway maintenance, ventilatory support, ECG monitoring, and rapid transport to an appropriate medical facility.

Describe the mechanism of injury, signs and symptoms, and prehospital management of pulmonary trauma.

1.Closed pneumothorax:
1.Mechanism of injury: Fractured rib that penetrates the underlying lung, excessive pressure on the chest wall against a closed glottis, or spontaneous.
2.Signs and symptoms: chest pain, dyspnea, and tachypnea.
3.Management: Ventilatory support with high-concentration oxygen.
2.Open pneumothorax:
1.Mechanism of injury: Develops when a chest injury exposes the pleural space to atmospheric pressure.
2.Signs and symptoms: shortness of breath, pain, and a sucking or gurgling sound as air moves in and out of the pleural space through the open chest wound.
3.Management: Close the chest wound, provide ventilatory support with high-concentration oxygen, treat the patient for shock by administering crystalloid per protocol, and rapidly transport the patient to an appropriate medical facility.
3.Tension pneumothorax:
1.Mechanism of injury: Air in the thoracic cavity that cannot exit the pleural space.
2.Signs and symptoms: Anxiety, cyanosis, increasing dyspnea, tracheal deviation (a late sign), tachycardia, hypotension or unexplained signs of shock, diminished or absent breath sounds on the injured side, distended neck veins, unequal expansion of the chest, subcutaneous emphysema.
3.Management: Directed at reducing the intrapleural pressure to atmospheric or subatmospheric levels.
4.Pulmonary contusion:
1.Mechanism of injury: Rapid deceleration forces.
2.Signs and symptoms: Tachypnea, tachycardia, cough, hemoptysis, apprehension, respiratory distress, dyspnea, evidence of blunt chest trauma, cyanosis.
3.Management: Ventilatory support and administration of high-concentration oxygen.
5.Traumatic asphyxia:
1.Mechanism of injury: Severe crushing injury to the chest and abdomen.
2.Signs and symptoms: reddish purple discoloration of the face and neck (the skin below the area remains pink), jugular vein distention, and swelling or hemorrhage of the conjunctiva (subconjunctival petechiae may appear).
3.Management: Directed at ensuring an open airway, providing adequate ventilation, and caring for associated injuries.

Describe the mechanism of injury, signs and symptoms, and prehospital management of injuries to the heart and great vessels.

1.Myocardial contusion:
1.Mechanism of injury: Usually caused by a vehicle collision.
2.Signs and symptoms: May have none, or patients may complain of chest pain similar to that seen with a myocardial infarction.
3.Management: Similar to that for myocardial infarction.
2.Pericardial tamponade:
1.Mechanism of injury: Penetrating trauma (and in rare cases, blunt trauma).
2.Signs and symptoms: Peripheral vasoconstriction, Beck triad (elevated central venous pressure, muffled heart sounds, and hypotension), tachycardia, respiratory distress, narrow pulse pressure, cyanosis of the head, neck, and upper extremities.
3.Management: Careful monitoring, oxygen administration, fluid replacement, and rapid transport to an appropriate medical facility.
3.Myocardial rupture:
1.Mechanism of injury: Occurs when blood-filled chambers of the ventricles are compressed with enough force to rupture the chamber wall, septum, or valve.
2.Signs and symptoms: Those of congestive heart failure and cardiac tamponade.
3.Management: Airway and ventilatory support and rapid transport for definitive care.
4.Traumatic aortic rupture:
1.Mechanism of injury: Rapid deceleration in high-speed motor vehicle crashes, falls from great heights, and crushing injuries.
2.Signs and symptoms: Unexplained shock and an appropriate mechanism of injury (rapid deceleration).
3.Management: Includes advising medical direction of the suspected rupture, administration of high-concentration oxygen, ventilatory support with spinal precautions, judicious fluid replacement (avoiding overhydration), and rapid transport for surgical repair.
5.Penetrating wounds of the great vessels:
1.Mechanism of injury: Usually involves injury to the chest, abdomen, or neck.
2.Signs and symptoms: Often accompanied by massive hemothorax, hypovolemic shock, cardiac tamponade, and enlarging hematomas that may cause compression of the vena cava, trachea, esophagus, great vessels, and heart.
3.Management: Directed at providing airway and ventilatory support, managing hypovolemia with judicious fluid therapy (guided by medical direction), and rapid transport for definitive care.

Outline the mechanism of injury, signs and symptoms, and prehospital care of the patient with esophageal and tracheobronchial injuries and diaphragmatic rupture.

1.Solid organ injury:
1.Liver:
1.Mechanism of injury: Trauma to the eighth through twelfth ribs on the right side of the body.
2.Signs and symptoms: Shock and peritoneal irritation.
3.Complications: Blood and bile escape into the peritoneal cavity.
2.Spleen:
1.Mechanism of injury: Motor vehicle crashes, falls, or sports injuries involving an impact to the lower left chest or flank or to the upper left abdomen.
2.Signs and symptoms: None, or pain in the left shoulder (Kehr sign).
3.Complications: Irritation of the adjacent diaphragm by a splenic hematoma or hemoperitoneum.
2.Hollow organ injury:
1.Stomach:
1.Mechanism of injury: Penetrating trauma.
2.Signs and symptoms: Those of peritonitis.
3.Complications: Leakage of acidic gastric contents.
2.Colon and small intestine:
1.Mechanism of injury: Penetrating trauma.
2.Signs and symptoms: Other injuries are usually present.
3.Complications: Peritoneal contamination with bacteria.
3.Retroperitoneal organ injury:
1.Kidneys:
1.Mechanism of injury: Abdominal trauma.
2.Signs and symptoms: Those of hemorrhage, extravasation of urine, or both.
3.Complications: Fractures and lacerations may require surgical repair, depending on which part of the kidney is damaged.
2.Ureters:
1.Mechanism of injury: Penetrating abdominal or flank wounds.
2.Signs and symptoms: Rarely injured.
3.Complications: Rarely injured.
3.Pancreas:
1.Mechanism of injury: Compressive or penetrating forces on the upper left quadrant, as in steering wheel and bicycle handlebar impairment.
2.Signs and symptoms: Those of other solid organs.
3.Complications: Those of other solid organs.
4.Duodenum:
1.Mechanism of injury: Great force from blunt trauma or a penetrating injury.
2.Signs and symptoms: Associated with concurrent pancreatic trauma; confirmed through surgery.
3.Complications: Those of crushing injuries or lacerations.
5.Pelvic organ injury:
1.Urinary bladder:
1.Mechanism of injury: May be ruptured by blunt trauma, penetrating trauma, or pelvic fracture.
2.Signs and symptoms: Gross hematuria.
3.Complications: Urine may enter the peritoneal cavity.
2.Urethra:
1.Mechanism of injury: Blunt trauma associated with pelvic fracture.
2.Signs and symptoms: Abdominal pain and inability to urinate.
3.Complications: An indwelling urinary catheter should not be used in these patients.

Outline the significance of injury to intraabdominal vascular structures.

1.Injury to intraabdominal vascular structures can be life-thratening because of their potential for massive hemorrhage.

Describe the prehospital assessment priorities for a patient suspected of having an abdominal injury.

1.Prehospital assessment priorities for a patient suspected of having an abdominal injury include obvious bleeding, pain and abdominal tenderness or guarding, abdominal rigidity and distention, evisceration, rib fractures, and pelvic fractures.

Outline the prehospital care of a patient with abdominal trauma.

1.A thorough scene survey to identify forces involved in abdominal trauma.
2.Rapid evaluation of the patient and the mechanism of injury.
3.Airway maintenance with spinal precautions.
4.Administration of high-concentration oxygen.
5.Ventilatory support as needed.
6.Reduction of hemorrhage by application of pressure.
7.Fluid replacement with volume expanders.
8.Use of a PASG (per protocol).
9.Cardiac monitoring.

Describe the features of each class of musculoskeletal injury.

1.Fractures: Breaks in the continuity of bone or cartilage.
2.Sprains: Partial tearing of a ligament caused by a sudden twisting or stretching of a joint beyond its normal range of motion.
3.Strains: Injuries to the muscle or its tendon from overexertion or overextension.
4.Joint dislocations: Injuries that occur when the normal articulating ends of two or more bones are displaced.

Describe the features of bursitis, tendonitis, and arthritis.

1.Bursitis: Inflammation of a bursa (a small, fluid-filled sac that acts as a cushion at a pressure point near joints).
2.Tendonitis: Inflammation of a tendon.
3.Arthritis: Inflammation of a joint.

Given a specific patient scenario, outline the prehospital assessment of the musculoskeletal system.

1.Patients can be divided into four classes:
1.Those with life- or limb-threatening injuries or conditions, including life- or limb- threatening musculoskeletal trauma.
2.Those with other life- or limb-threatening injuries and only simple musculoskeletal trauma.
3.Those with no other life- or limb-threatening injuries but with life- or limb-threatening musculoskeletal trauma.
4.Those with only isolated injuries that are not life or limb threatening.
2.The paramedic should perform an initial assessment to determine whether the patient has any conditions that pose a threat to life.
3.Evaluation of an injured extremity should always include checking the “six Ps”:
1.Pain.
2.Pallor.
3.Paresthesia.
4.Pulses
5.Paralysis.
6.Pressure.
4.DCAP-BTLS
1.Deformity.
2.Contusions.
3.Abrasions.
4.Penetrations or punctures.
5.Burns.
6.Tenderness.
7.Lacerations.
8.Swelling.
5.If possible, the assessment should include comparison with the opposite, uninjured extremity.

Outline general principles of splinting.

1.Splint joints and bone ends above and below the injury.
2.Immobilize open and closed fractures in the same manner.
3.Cover open fractures to minimize contamination.
4.Check pulses, sensation, and motor function before and after splinting.
5.Stabilize the extremity with gentle in-line traction to a position of normal alignment.
6.Immobilize a long bone extremity in a straight position that can be splinted easily.
7.Immobilize dislocations in a position of comfort; ensure good vascular supply.
8.Immobilize joints as found; joint injuries are aligned only if no distal pulse is felt.
9.Apply cold to reduce swelling and pain.
10.Apply compression to reduce swelling.
11.Elevate the extremity if possible.

1.Shoulder injury:
1.Significance: Common in older adults.
2.Management: Assessment of neurovascular status, application of a sling and swathe, and application of ice.
2.Humeral injury:
1.Significance: Common in older adults and children.
2.Management: Assessment of neurovascular status, realignment if vascular compromise is present, application of a rigid splint and sling and swathe or splinting of the extremitiy with the arm extended, and application of ice.
3.Elbow injury:
1.Significance: Common in children and athletes.
2.Management: Assessment of neurovascular status, splinting in the position pound with a pillow, blanket, rigid splint, or sling and swathe, and application of ice.
4.Radial, ulnar, or wrist injury:
1.Significance: Usually are the result of a fall on an outstretched arm.
2.Management: Assessment of neurovascular status, splinting in the position found with rigid or formable splints or a sling and swathe.
5.Hand (metacarpal) injury:
1.Significance: Often results from contact sports, violence (fighting), and work-related crushing injuries.
2.Management: Assessment of neurovascular status, splinting with a rigid or formable splint in the position of function, and application of ice and elevation.
6.Finger (phalangeal) injury:
1.Significance: May be immobilized with foam-filled aluminum splints or tongue depressors.
2.Management: Assessment of neurovascular status, splinting as previously described, and application of ice and elevation.

1.Pelvic fracture:
1.Significance: Blunt or penetrating injury to the pelvis may result in fracture, severe hemorrhage, and associated injury to the urinary bladder and urethra.
2.Management: Administration of high-concentration oxygen, management for shock, full-body immobilization on a long spine board, regular monitoring of vital signs, and rapid transport.
2.Hip injury:
1.Significance: Commonly occur in older adults as a result of a fall.
2.Management: Assessment of neurovascular status, splinting with a long spine board and generously padding the patient for comfort during transport, and frequent monitoring of vital signs.
3.Femoral injury:
1.Significance: Usually results from major trauma, such as may occur with motor vehicle crashed and pedestrian injuries.
2.Management: Administration of high-concentration oxygen, management for shock, assessment of neurovascular status, application of a traction splint, and regular monitoring of vital signs.
4.Knee and patellar injury:
1.Significance: Fractures of the knee (supracondylar fracture of the femur, intraarticular fracture of the femur or tibia) and fractures and dislocations of the patella commonly relust from motor vehicle crashes, pedestrian injuries, contact sports, and falls on a flexed knee.
2.Management: Assessment of neurovascular status, splinting in the position found with a rigid or formable splint that effectively immobilizes the hip and ankle, and application of ice and elevation, if possible.
5.Tibial and fibular injury:
1.Significance: May result from direct or indirect trauma.
2.Management: Assessment of neurovascular status, splinting with a rigid or formable splint, and application of ice and elevation.
6.Foot and ankle injury:
1.Significance: May result from a crushing injury, a fall from a height, or a violent rotating or twisting force.
2.Management: Assessment of neurovascular status, application of a formable splint, such as a pillow, blanket, or air splint, and application of ice and elevation.
7.Phalangeal injury:
1.Significance: Often caused by “stubbing” the toe on an immovable object.
2.Management: Assessment of neurovascular status, buddy splinting, and application of ice and elevation.

Identify prehospital management priorities for open fractures.

1.Should be covered with sterile, dry dressings.
2.Should not be irrigated in the field or soaked with any type of antiseptic solution.
3.Hemorrhage should be controlled with direct pressure and pressure dressings.
4.If a bone end or bone fragment is visible, it should be covered with a dry, sterile dressing and splinted.
5.Bone ends that slip back into the wound during immobiliation should be noted and reported to the receiving hospital so that the bone can be cleaned during surgery.

Describe the principles of realignment of angular fractures and dislocations.

1.Finger realignment:
1.Apply in-line traction along the shaft of the finger.
2.Continue with slow, steady traction until the finger is realigned and the patient feels relief from pain.
3.Immobilize the finger with a splint device or by buddy splinting.
2.Shoulder realignment:
1.Attempt realignment only in the absence of severe back injury.
2.Check circulatory and sensory status.
3.Apply slow, gentle longitudinal traction, with countertraction exerted on the axilla.
4.Slowly bring the extremity to the midline.
5.Immobilize with a sling and swathe.
3.Hip realignment:
1.Apply in-line traction along the shaft of the femur with the hip and knee flexed at 90 degrees.
2.Continue with slow, steady traction to reduce the muscle spasm.
3.Immobilize the leg in full extension with the patient positioned on a long spine board.
4.If full extension is not achieved, immobilize the leg at a flexion not to exceed 90 degrees with pillows of blankets.
4.Knee realignment:
1.Apply gentle, steady traction while moving the injured joint into normal position.
2.Successful realignment is indicated by a “pop” into the joint, resolution of deformity, relief of pain, and increased mobility.
3.Immobilize the leg in full extension.
5.Ankle realignment:
1.Apply in-line traction on the talus while stabilizing the tibia.
2.Successful realignment is noted by a sudden rotation to a normal position.
3.Immobilize the ankle in the same manner as for a fracture.

Outline the process for referral of patients with a minor musculoskeletal injury.

1.Evaluate the need for immobilization.
2.Evaluate the need for radiography.
3.Evaluate the need for emergency department assessment versus the patient going to his or her private physician.
4.Consult with medical direction.